Differentialdiagnose und Behandlung akuter Verwirrtheit bei psychischen Störungen

Abstract

In classical and contemporary German and Swiss psychiatry the term confusional (akuter Verwirrtheitszustand) describes an ill-defined complex of symptoms and signs of heterogeneous pathogenesis characterised by a lack of comprehensibility and incoherence of actions and verbal expressions. It is frequently associated with suddenly developing or severe episodes of psychotic or affective disorders. In this context we address the issue of the currently increasing disenchantment with the disease-entity assumption (Kendell and Jablensky, 2003) because there is still little evidence that most currently recognised mental disorders, which are in principle based on the psychopathologically defined signs and findings, are separated by natural boundaries. In the following article we intend to give a review of some pertinent issues in relation to the clinical features, assumed pathogenesis and differential diagnosis related and limited to confusional states during acute states of affective or psychotic disorders focused on the following particular group of psychiatric disorders: acute and transient psychotic disorders (especially the cycloid psychoses according to Leonhard), severe depressive episodes, manic and mixed episodes. Brief psychotic disorder is defined by the presence of delusions, hallucinations, disorganised speech or grossly disorganised or catatonic behaviour, a duration of at least one day but less than one month and eventual full return to the premorbid level of functioning. Practice guidelines for the psychopharmacological treatment of patients with brief psychotic disorder remain controversial. Delirious mania is a syndrome of acute onset, the patients are excited, grandiose, emotionally labile and suffer from delusions and insomnia characteristic of mania. An additional characteristic is the disorientation and altered consciousness typical of delirium. Catatonia frequently accompanies the clinical picture. The difficulty in distinguishing delirious mania from excited or malignant catatonia is emphasised. Moreover, until the concepts of these particular psychiatric syndromes are clarified, we lack valid criteria to accurately separate delirious mania, malignant catatonia, excited catatonia, rapid-cycling mania and mania with psychotic features (Fink, 1999). Finally, some unintended and sometimes unrecognised toxic side effects during otherwise correct psychopharmacologic treatments of these disorders with dopamine receptor antagonists or serotonergic antidepressant medications that require early diagnosis and therapeutic intervention are described: neuroleptic malignant syndrome, serotonin syndrome and drug-induced hyponatraemia. These particular drug-induced states are selected because they are often accompanied by an acute confusional state and they can resemble the original illness-related state.